An Evidence-Based Guideline for the Pre-Operative Sedation of Children

Journal of Pediatrics and Neonatal Care An Evidence-Based Guideline for the Pre-Operative Sedation of Children Abstract Review Article There are numerous sedative pharmacological agents currently administered to Volume 2 Issue 6 - 2015 children as premedicants to facilitate the induction of anaesthesia. When preoperative sedation is required, selection of the appropriate drug is imperative to Deborah M Fradkin*, Victoria L Scott- provide adequate anxiolysis whilst minimising unwanted side effects. We review Warren, Rita Vashisht and Sian E Rolfe the literature regarding the merits and limitations of the commonly used agents and suggest evidence based practical guidance. For the anxious but cooperative Department of Paediatric Anaesthesia, Royal Manchester Children’s Hospital, England child, oral midazolam is often adequate; however with more anxious younger and uncooperative children, combined oral midazolam and ketamine is more *Corresponding author: DM. Fradkin, Department of effective. Other oral benzodiazepines and oral clonidine all have their role when Paediatric Anaesthesia, Royal Manchester Children’s used in the appropriate circumstances. Intranasal clonidine is useful in the child Hospital, Oxford Road, Manchester, M13 9WL, England, Tel: refusing oral medication. Intramuscular ketamine should be reserved for extreme 0161 701 1264; Email: circumstances, administered only by anaesthetists experienced in its use, with full monitoring and resuscitative equipment immediately available. Received: August 15, 2015 | Published: September 08, 2015 Keywords: Conscious sedation; Anxiolytics; Paediatric Anaesthetics; Premedication; Preoperative care Abbreviations: PO: Oral; IN: Intranasal; IM: Intramuscular; always obvious. Use of an inappropriate agent or dose can produce side effects such as cardiorespiratory depression. Conversely, an inappropriate agent may lead to inadequate sedation of an already IntroductionOTMF: Oral Transmucosal Fentanyl; GABA: ƴ-Aminobutyric acid anxious non-cooperative child, causing increased distress for both the child and parent, resulting in abandoning the induction Information regarding the variety of pre-medications and and delaying surgery. their appropriateness in different clinical situations is dispersed widely within the literature and therefore not easily comparable This document reviews the available literature and provides at a glance. Working at a tertiary paediatric hospital, with a large guidance on the prescribing and administration of pre-operative turnover of trainees with limited prior exposure to paediatric sedative drugs to facilitate the induction of anaesthesia in healthy anaesthesia, we felt it was imperative to create robust evidence children. Its use is not intended for procedural sedation or based guidelines, bringing together the information available into sedation to facilitate diagnostic investigations. The premedication one easily accessible, clear, concise and comprehensive document. of children with severe cardiorespiratory or neurological This guidance, although produced for a tertiary hospital, is a disease is beyond the scope of this document and will require a useful tool to facilitate safe practice and minimise inappropriate personalised approach determined by a consultant anaesthetist. drug selection and dosing for any anaesthetist with an interest in Similarly, in individual cases, drugs and dosages not covered in paediatrics. this guideline may be considered appropriate by a consultant anaesthetist. Premedication is drug treatment given to a patient usually before medical or surgical procedures. The aim of premedication These medications should be prescribed only by anaesthetists in children and young people is to produce a relaxed state with and following thorough anaesthetic assessment of the patient. Of reduced anxiety and increased compliance, allowing the patient note, as rectal administration of sedation is not favoured by either to tolerate and co-operate with the necessary procedure. the anaesthetist or parents at our trust this has not been included This is commonly achieved by appropriate administration of in our guidelines. pharmacological agents, typically sedative or analgesic. After effective premedication, patients may exhibit an altered level of The practicalities and logistics of paediatric patients consciousness but should retain the ability to independently and having preoperative sedation must always be considered continuously maintain a patent airway, follow verbal commands, prior to prescribing and administration. A suggested practical and respond appropriately to tactile stimulation [1-3]. management to optimise patient care and minimise risk is suggested in our supporting information (section 9). The spectrum of children requiring sedative premedication for induction of anaesthesia varies from the anxious but Discussion cooperative, the anxious and uncooperative, to those with severe Guideline for oral premedication would not tolerate induction of anaesthesia without sedation. Midazolam: Oral (PO) premedication is easier to administer and Withdevelopmental a large selection delay and of behaviouralavailable pharmacological difficulties some agents, of whom the better accepted than other possible routes of drug administration most appropriate premedicant for an individual child is not [4]. The ability to hide PO premedication within a carrier liquid (a Submit Manuscript | http://medcraveonline.com J Pediatr Neonatal Care, 2(6): 00095 Copyright: An Evidence-Based Guideline for the Pre-Operative Sedation of Children ©2015 Fradkin et al. 2/7 useful for the uncooperative patient with behavioural or secretion or postoperative nausea and vomiting [4,18,19] and flavoured drink or ibuprofen syrup if appropriate) is particularly withadequate no evidence sedation of emergencewithout delirium.significantly At higherincreasing doses thanoral administration of a small volume of liquid (less than 10mls) pre- recommended (>5mg/kg) it can lead to an increase in nystagmus operativelylearning difficulties. does not Oflead note to anthere increased is evidence aspiration that the risk paediatric [5]. [4], vomiting and hallucinations [23]. Combined midazolam and ketamine can lead to effective benzodiazepine, it acts as both an anxiolytic and hypnotic agent, anxiolysis without sedation. Funk found that excess sedation did modulatingPO midazolam the effects is aof commonlythe main inhibitory used first neurotransmitter line agent. A not occur [18], and Warner stated all children in their study who were sleeping were easy to rouse, and the majority were awake at GABAA receptors [6]. The dose of 0.5mg/kg has been well and calm (in this study 0.02mg/kg atropine, itself mildly sedative, establishedwithin the central through nervous various system, studies, ƴ-Aminobutyric with lower doses acid providing (GABA), was also used) [14]. When sedation does occur, it is normally inadequate anxiolysis [5,7] and higher doses potentially causing within 15-30minutes of administration [4]. In addition, there dysphoric reactions [8], ataxia and prolonged sedation, without is no evidence of hypoxia, with studies demonstrating oxygen improving anxiolysis [9]. Respiratory and cardiovascular saturations remaining above 97% [18] and 99% [19] with no depression may occur [6,10]. Administration of 0.5mg/kg oral change in respiratory rate [19]. midazolam (maximum dose 20mg) will provide anxiolysis as early as 15 minutes, with anterograde amnesia occurring as early as premedication with a combination of ketamine and midazolam 10 minutes post dose; however peak sedation may take up to 30 Although some studies find no delay in recovery [18], minutes to occur [11,12]. The evidence that PO midazolam leads in discharge from recovery postoperatively [17,19], with a mean to delayed discharge from recovery is variable [13]. However, the recoverymay lead dischargeto a slight time (although of 51 minutesnot statistically in one study significant) [19], and delay 54 minutes in another [17] (compared to the control of 40 minutes, disadvantage of a potentially prolonged recovery stay. benefit associated with appropriate premedication outweighs the and 39 minutes with midazolam alone, respectively). Combined midazolam and ketamine: Midazolam as a sole A combination of midazolam and ketamine should therefore to administer, with a rapid onset and relatively short duration. in anxious and uncooperative children and children with Howeveragent fits itsmany degree of the of criteria success of makes an ideal it premedicant,less than ideal. being Good easy or behaviouralbe considered or developmentalas first-line choice issues. for However, paediatric when premedication this option excellent results are only seen in 60-80% of patients with many is contraindicated (e.g. a history of paradoxical excitation with studies reporting lower success rates [5,8,14]. Children who are midazolam) we do not recommend ketamine alone. This is more anxious and emotional, or those below four years old, are more likely to be inadequately sedated by midazolam alone [15]. dose to produce adequate sedation and anxiolysis [4] leading Children with diagnosed developmental delay and/or behavioural tobecause increased its use side as effects. a sole Inagent this requires situation, a alternativessignificantly suchgreater as clonidine, lorazepam or temazepam may be useful premedicants. effective anxiolysis [2,16]. However such doses expose them todifficulties risks of oftensedation need such larger as dosesreduced of sedativerespiratory

Load more